The symphony of open-heart surgical care: A mixed-methods study about interprofessional attitudes towards family involvement

ABSTRACT Purpose The overall aim of this study was to describe the attitudes towards family involvement in care held by nurses and medical doctors working in open-heart surgical care and the factors influencing these attitudes. Methods Mixed-methods convergent parallel design. A web-based survey was completed by nurses (n = 267) using the Families’ Importance in Nursing Care-Nurses Attitudes (FINC-NA) instrument and two open-ended questions, generating one quantitative and one qualitative dataset. Qualitative interviews with medical doctors (n = 20) were conducted in parallel, generating another qualitative dataset. Data were analysed separately according to each paradigm and then merged into mixed-methods concepts. Meta-inferences of these concepts were discussed. Results The nurses reported positive attitudes in general. The two qualitative datasets from nurses and medical doctors resulted in the identification of seven generic categories. The main mixed-methods finding was the attitude that the importance of family involvement in care depends on the situation. Conclusions The dependence of family involvement on the situation may be due to the patient’s and family’s unique needs. If professionals’ attitudes rather than the family’s needs and preferences determine how the family is involved, care runs the risk of being unequal.


Introduction
Open-heart surgery, e.g., coronary artery bypass grafting, aortic procedures and cardiac valve replacement, is a common treatment for cardiovascular diseases (Head et al., 2017;Stephens & Whitman, 2015). Coronary artery bypass grafting is the most frequent cardiac surgical procedure in high-income countries (Head et al., 2017;McDermott & Liang, 2021), with a rate of approximately 63 per 100 000 inhabitants in the US (McDermott & Liang, 2021) and 44 of 100 000 in western Europe (Head et al., 2017). However, openheart surgery may lead to life-threatening complications. Because of these risks, patients need to be monitored and cared for in an advanced, highly technological postoperative environment by a multiprofessional team (Stephens & Whitman, 2015). Just as a symphony requires an orchestra, open-heart surgical care requires a multiskilled team of professionals with various perspectives on patient care. A team consisting of cardiothoracic surgeons, anaesthesiologists, intensive care nurses, surgical nurses, physiotherapists, and other healthcare professionals (Stephens & Whitman, 2015) makes interprofessional collaboration essential for care quality and safety (Pomare et al., 2020;World Health Organization, 2010). Patients are often dependent on their families during the rehabilitation phase at home (Bjørnnes et al., 2019). Family involvement in care is recommended internationally (Davidson et al., 2017;Johnson & Abraham, 2012;Shajani & Snell, 2019) and has been known to improve both patient (Eskes et al., 2019;Mackie et al., 2019) and family (Bjørnnes et al., 2019;Joseph et al., 2015) outcomes.
The meaning of family involvement in care has a broad definition in this study. Family includes not only relations by bloodline or law but also emotional relationships . Family involvement requires family presence, information sharing, and the facilitation of family members' participation in shared decision making and basic care activities (Olding et al., 2016). Furthermore, family involvement means that family members should be supported and have their own needs met by health care professionals (Olding et al., 2016).
Postoperative recovery may be enhanced when the family is involved in preventive patient care targeting surgical complications (Eskes et al., 2019), leading to an improvement in family satisfaction with care (Bjørnnes et al., 2019). The risks and consequences of open-heart surgery put a strain on both the patient and the patient's family in terms of stress and anxiety (Bjørnnes et al., 2019;Joseph et al., 2015;Kemp et al., 2020;Robley et al., 2010). The family plays a key role in rehabilitation following open-heart surgery, a responsibility they are not always prepared for (Bjørnnes et al., 2019). Preoperative anxiety is associated with impaired postoperative recovery for the patient and may double all-cause mortality after open-heart surgery (Joseph et al., 2015). It has been suggested that stress and anxiety can be reduced for both family and patients when the family is involved in the care of their ill family member (Bjørnnes et al., 2019;Mackie et al., 2019). Attitudes of the health care team towards family involvement in care influence how families are treated and involved (Bell, 2013;Mackie et al., 2018). An attitude may be defined as a state of believing, valuing, or feeling something that predisposes an action or behaviour (Altmann, 2008). Attitudes predispose how we act, but this does not mean that we always act according to our attitudes (Altmann, 2008). Attitudes can be either conscious or unconscious and therefore cannot be measured directly and may be illuminated in our behaviour (Bakanauskas et al., 2020). Attitudes towards family involvement in care have been known to vary between care contexts and groups of health care professionals (Al Mutair et al., 2013;Barreto et al., 2022;Benzein, Johansson, Årestedt, Berg, et al., 2008;Davis et al., 2014;Dijkman et al., 2021;Jordan et al., 2014;R. Laidsaar-Powell et al., 2017;Rosland et al., 2011;Shin et al., 2017). Nurses' attitudes towards family involvement have been explored to some extent in the context of cardiology (Gusdal et al., 2017;Luttik et al., 2017), surgical care (Blöndal et al., 2014) and a general nursing context (Benzein, Johansson, Årestedt, Berg, et al., 2008;Østergaard et al., 2020). Nurses generally hold positive attitudes towards family involvement in care, but some variations related to nurses´ personal experiences, educational level and context of workplace have been found in previous studies (Barreto et al., 2022). There are also significant differences in nurses' attitudes between countries (Cranley et al., 2022;Shamali et al., 2022). At times, nurses' negative attitudes may hinder family involvement, such as holding the belief that the patient comes first and family members take time away from patient care (Mackie et al., 2018). Research on medical doctors' (MDs) attitudes towards family involvement in care has mostly focused on primary, geriatric and oncology care settings (Dijkman et al., 2021; R. C. Laidsaar-Powell et al., 2013;Rosland et al., 2011;Shin et al., 2017). Aspects of family involvement in care from the perspective of MDs in previous studies are shared decision making, communication and family presence (Dijkman et al., 2021;Jordan et al., 2014;R. C. Laidsaar-Powell et al., 2013;Shin et al., 2017). Surgeons' interactions with families have been reported to vary (Jordan et al., 2014). For example, some always include the family in their preoperative communications while others never do (Jordan et al., 2014). Studies including both nurses' and MDs' attitudes towards family involvement in the care of adult patients are limited (Al Mutair et al., 2013;Davis et al., 2014;R. Laidsaar-Powell et al., 2017). When compared, nurses (R. Laidsaar-Powell et al., 2017), patients and families (Shin et al., 2017) hold more positive attitudes towards family involvement in oncology care than MDs. On the other hand, MDs tend to be more positive than nurses to family involvement in patient-safety practices in the acute care setting (Davis et al., 2014).
Because of the complexity of capturing attitudes, a mixed-methods approach was considered beneficial for the description of attitudes towards family involvement from informants from various professions. The merging of qualitative and quantitative results enables comparisons to be made, and a more complete understanding emerges than that provided by the quantitative and qualitative results alone. The overall aim was to describe the attitudes towards family involvement in care held by nurses and medical doctors working in open-heart surgical care and the factors influencing these attitudes.
The study aim was based on the following research questions.
• How do nurses and medical doctors working in open-heart surgical care describe their attitudes towards family involvement in care and the factors affecting these attitudes? (Qualitative) • How do nurses working in open-heart surgical care rate the importance of family involvement in nursing care? (Quantitative) • Is age, education and/or previous experiences associated with nurses' ratings of their attitudes towards family involvement in nursing care?
To what extent do these attitudes and components converge and diverge? (Mixed-methods)

Design
A mixed-methods convergent parallel design was used. This is a type of design in which qualitative and quantitative data are collected in parallel and analysed separately, and then the results are merged and meta-inferences can be made (Creswell & Plano Clark, 2018). The reporting in this study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (von Elm et al., 2014) and the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007). Strategies to minimize validity threats in convergent mixed-method design (Creswell & Plano Clark, 2018) is applied in this study. The mixed-methods convergent parallel process is presented in Figure 1.

Setting
Patient autonomy and rights to participate in their own care is emphasized in c 3 § 4 of the Swedish Patient Act (SFS, 2014). In c 5 § 3, the family's right to be involved in patient care is also established, given that the patient cannot receive information himself or herself and if it is deemed appropriate (SFS, 2014). In Sweden, open-heart surgical care is organized similarly in eight hospitals, seven of which are university hospitals. When a surgical indication is identified, the patient is referred to the cardiothoracic surgical department from the cardiology department. Patients are cared for in a surgical ward, the operating theatre, the intensive-care unit, and at some departments, a step-down unit. These units are staffed with health care professionals with various educational backgrounds, such as nurse assistants; registered nurses (some having a vocational degree and others having a bachelor's degree); nurses with a postgraduate diploma in surgery, anaesthesiology or cardiology (some holding a master's degree); physiotherapists (some holding a master's degree in respiratory therapy or intensive care); occupational therapists; and MDs in training to become specialized in cardiology, cardiothoracic surgery or anaesthesiology. In addition to the abovementioned, resident cardiothoracic anaesthesiologists and surgeons work in all units. All units have close collaboration; for this study, nurses and MDs were included from the intensive care units, step-down units and/or surgical wards since these are places where family members are invited to visit. Family involvement in the operation theatre is an unusual exception in this context and foremost an issue when the patient is a child.

Nurses
Nurses included in this study were recruited from all eight cardiothoracic departments in Sweden from April-November 2020. Data collection was planned for March-April 2020, but this period was the first wave of the COVID-19 pandemic in Sweden. Therefore, the departments themselves chose when to participate in this study, and they were given the opportunity to adjust the timing of their participation to their workload in relation to the strain of pandemic care. Three clinics agreed to complete the Families' Importance in Nursing Care-Nurses Attitudes (FINC-NA) instrument from April-September 2020, while the remaining five clinics completed the instrument from September-November 2020. The nurses were instructed to answer while thinking of the normal situation when there were normal routines for family involvement in care. The inclusion criteria were 1) being employed as a nurse at one of the wards included in the study and 2) caring for patients undergoing elective open-heart surgery and meeting these patients' families.
After written consent was obtained from the head of each department, email addresses for the nurses were retrieved. Written information about the study was sent out via workplace email to 650 eligible participants. One week after the information was distributed, an electronic questionnaire was sent out via a unique link to each participant. Nurses willing to participate gave their consent by answering and submitting the questionnaire anonymously. Three reminders were sent to the first group, and four reminders were sent to the second group. Figure 1. The mixed method convergent design process: Data collection, analysis, merging and meta-inference.

Medical doctors
The MDs included in this study were recruited from three out of the seven cardiothoracic departments situated at university hospitals in Sweden. The MDs were working at the aforementioned university hospitals from April-November 2020.
The inclusion criteria were 1) being employed as an MD at one of the three cardiothoracic centres included in this part of the study and 2) treating patients undergoing elective open-heart surgery and meeting these patients' families.
Recruitment of participants for the individual interviews started with an oral presentation in two out of three study sites. Due to travel restrictions during spring 2020, it was not possible to visit the third study site as planned to provide group information to the MDs. Written information about the study was sent via workplace email to all cardiothoracic surgeons and anaesthesiologists working at the three study sites (n = 133). MDs were recruited via convenience sampling, and all MDs interested in participating were included except for one who was no longer employed by the department at the time for data collection. MDs interested in participating answered the email, and an interview was scheduled.
The characteristics of the nurses and MDs are presented in Table I.

Families' importance in nursing carenurses' attitudes (FINC-NA)
The FINC-NA was originally developed as a generic measurement of nurses' attitudes towards the importance of families in nursing care, and it was validated in Swedish . It has since been refined (Saveman et al., 2011), and the refined version was used in this study. The FINC-NA consists of 26 items and uses a 5-point Likert-type scale ranging from "totally agree" to "totally disagree" (Saveman et al., 2011). The minimum possible score for the total scale is 26, and the maximum is 130. The higher the score, the more supportive nurses' attitudes towards families in nursing care are. The FINC-NA has four subscales. Family as a resource in nursing care (Fam-RNC) assesses positive aspects of how the family influences the nurse's work and the importance of family presence for nursing care. Family as a conversational partner (Fam-CP) concerns the nurse's inclusive work with families when planning care, mapping out who belongs to the family, and communicating and inviting the family to participate in care planning and nursing care. Family as a burden (Fam-B) covers negative aspects of family involvement, such as whether the nurse is stressed by the family or does not have time for families; this scale is reverse scored. Family as own resource (Fam-OR) concerns how the nurse collaborates with and supports the family, enhancing the family's own resources as a strategy for them to cope with the situation. The α reliability coefficients are .89 for the whole instrument and between .71 to .86 for the four subscales (Saveman et al., 2011). The original authors gave their permission to use the instrument for nurses but not for MDs since it was not developed for use in the MD population.

Open-ended questions in the instrument
The FINC-NA was concluded with two open-ended questions added by the authors of this study. The open-ended questions for the nurses were intended to ask questions similar to those for the MDs, as parallel questions facilitate the merging of results in a mixed-methods convergent parallel design (Creswell & Plano Clark, 2018).
The two questions were as follows: (1) What does family involvement mean to you? (2) What influences your attitude towards family involvement in care?
The answers to these open-ended questions were described by the participating nurses in a total of 15,919 words, which was the dataset to be included in the qualitative analysis.

Qualitative interviews
The key structure of the FINC-NA (Saveman et al., 2011) guided the construction of semistructured questions for the qualitative interviews with the MDs. Areas covered by the interview guide were the meaning of family involvement, family members' role in caregiving, negative and positive aspects of family involvement and what the participant thought influenced his or her attitudes towards family involvement in care. After conducting two pilot interviews with two MDs not eligible as study participants, the first author received feedback from the co-authors on the interview technique. The pilot interviews were not included for analysis in this study. The original opening question was "What does family involvement mean to you?" This question prompted the participants answer with a general statement regarding semantics of the phrase "family involvement" as opposed to describing their own personal attitudes. The question was therefore altered to "Think back to a situation when family were involved in the care you gave. Please describe the situation." Prompting questions such as "How was that for you?" were also used.
Twenty MDs participated in qualitative interviews in the study. The first author conducted all interviews. They were held at the place of the participant's choice, usually in the participant's private office at the clinic. Seven interviews were held using a videoconferencing platform (i.e., Zoom) due to national travel restrictions during the COVID-19 pandemic. The interviews lasted 24-97 minutes, with a median of 50 minutes. All interviews were audio recorded and transcribed verbatim by a professional transcriber and formed the basis of the analysis.

Analysis
The analysis was conducted in four separate steps consisting of 1) statistical analysis of the FINC-NA scores, 2) qualitative content analysis of the answers to the open-ended questions, 3) qualitative content analysis of the transcribed interview data and 4) mixed-methods merging and meta-inference using a side-by-side joint display.

Statistical analysis
The quantitative data were analysed using descriptive statistics. Continuous variables are presented as the median and interquartile range (q1; q3), and categorical variables are presented as numbers and percentages. The Fam-B scale scores were reversed prior to analysis, making all scores indicate attitudes in the same direction from 1 (negative) to 5 (positive). The Mann-Whitney U test was performed for comparisons between groups by sex, educational degree, possession of a postgraduate diploma in nursing, and experience of being a patient or a family member of a patient. The correlations between age of the nurses and subscales and between years of experience as a nurse and subscales were analysed with Spearman's rank correlation (r s ). Missing data (1.2%) were not imputed, and cases with missing data were listwise deleted. To be included in the analysis, a minimum of 60% of the items on the FINC-NA had to be answered. The participants' academic degrees were dichotomized into basic (vocational and bachelor's degrees) and advanced (master's and doctoral degrees) levels. The "prefer not to say" answer to demographic questions was treated as missing in the dichotomous group analysis. All tests were twosided and conducted at the 5% significance level. Statistical analyses were performed using IBM SPSS Statistics (Version 26) software.

Qualitative content analysis
All qualitative data were analysed independently by all authors who had diverse preunderstandings. The authors' clinical backgrounds were in the cardiothoracic care setting as nurses (AD, ASS, SÅ), in general surgical care as a nurse anaesthetist (EE) and in stroke and primary care as a physiotherapist (MLAL). All authors had experience conducting qualitative analysis. Analysis of free text answers in the questionnaire and the transcribed interviews was made separately and followed Elo and Kyngäs's (2008) description of inductive qualitative content analysis. The first author independently analysed all interviews and all the material from the open-ended questions. All data from the interviews and all the material from the open-ended questions were divided between the other co-authors for individual analysis. Initially, all authors independently analysed the material by open coding, transferring the codes to a coding sheet, and thereafter grouping codes into preliminary categories. After this, the authors' individual analysis was compared and discussed within the research group until agreement was reached. Hence, all data were analysed individually by two authors until the grouping stage of Elo and Kyngäs's (2008) analysis process. After discussion, agreement regarding the grouping was reached. At this stage, the first author expanded the analysis through Elo and Kyngäs's (2008) categorization. The expanded analysis was then discussed within the research group until agreement was reached.

Mixed-methods merging and meta-inference
This study's mixed-methods research question was "To what extent do attitudes towards family involvement in care held by nurses and medical doctors working in open-heart surgical care and the factors affecting these attitudes converge and diverge?". To answer this question, the three datasets were merged, using a side-by-side joint display (Creswell & Plano Clark, 2018). The merging of results was expected to yield greater insight into the phenomenon of attitudes towards family involvement in care held by nurses and MDs than each unit of data separately would. In the instances where merging is the integration procedure, a side-by-side joint display is recommended (Younas & Durante, 2022). The headings and textual descriptions of the generic categories and groupings from the two qualitative datasets were initially contrasted inductively by the first author by their overarching themes. Thereafter, the descriptions of the FINC-NA subscales were contrasted by the first author against the themes identified in the two qualitative datasets. The descriptions of the FINC-NA subscales and median values and results from analytical statistical tests in each subscale and on total scale level were organized according to the preliminary themes and their correspondence to one and another. When displayed for contrast and comparison, the content of the results was merged into concepts of convergent and divergent attitudes. At this stage, the merging and meta-inference was discussed within the research group until agreement was reached. The last step in the mixed-methods convergent parallel design process, the meta-inference of the concepts, is discussed in the discussion section of this article. An example from the side-by-side joint display table used for the mixed-methods merging and metainference is presented in Table II.

Ethical considerations
The study was approved by the Swedish Ethical Review Authority (No 2019-06315), and it conforms with the principles outlined in the Declaration of Helsinki (World Medical Association, 2013). Some of the participants were recruited from the first, fourth and last authors' workplaces. The first author conducted all interviews. The written information was at times followed up with oral information by the first or fourth author during clinical duty. This oral information was given on the request of the MD without pressure to participate. No author, except for the first author, analysed the interviews of MDs with whom they had a professional relationship. Since the data from the nurses were anonymized, professional relationships between participants and authors could not be determined in this dataset. The timing of this study could be considered burdensome for the participants, considering the workload during the first year of the COVID-19 pandemic. On the other hand, participants might have felt good about the opportunity to reflect and share their thoughts on this issue during a time when several aspects of family involvement were limited.

Results from the FINC-NA completed by nurses
In total, 267 out of the 650 eligible nurses returned the FINC-NA with at least a 60% completion grade, giving a total response rate of 41%. Response rates from the eight clinics varied between 27.9-55.6%. Complete responses (i.e., responses on all 26 items) were returned by 222 out of the 267 included nurses. The median score for the FINC-NA total scale was 93 (Q1 = 85 Q3 = 104). Descriptive results from the total FINC-NA and the four subscales and items are presented in Table III.
Internal consistency for subscales was reliable, with Cronbach's alphas between .71 and .88 for the four subscales and .90 for the total scale. Overall FINC-NA scores were high, indicating positive attitudes towards the importance of families in nursing care. There was no significant difference in the FINC-NA total score by age, sex, years of experience as a nurse, academic level, or experience of either being a patient or being a family member to a patient. Female participants held more positive attitudes on the Fam-RNC subscale than male participants (p = 0.004). Nurses with an advanced educational degree (i.e., master's or doctoral degrees) showed a significantly higher ranking on the reversed score Fam-B subscale than nurses with vocational or bachelor's degrees (p = 0.003). Having a postgraduate diploma in nursing was associated with a more positive attitude towards families on the Fam-CP (p = 0.040) and Fam-B (p = 0.013) subscales.
A poor correlation to no correlation was found between the nurses' ages and the subscales (r s = −.12-.08) and between years of experience as a nurse and the subscales (r s = −.05-.16).
Analyses of differences on the subscales and background variables are presented in Table IV.

Results from open-ended questions answered by nurses
Out of the 267 nurses included in the quantitative analysis, 206 answered at least one of the two open-ended questions. Analysis of this material generated three generic categories: affecting the quality of care, including family in their mission, and influential aspects. Quotes illustrating the categories are displayed in Table V.

Affecting the quality of care
The nurses believed that family involvement affected the quality of care, both in a positive and negative way. Information about the patient provided by family members was considered a means for the nurses to give personalized care and for the family to act as the patient's voice when they could not speak for themselves. Some reported that family involvement eased the nurse's workload and facilitated nurse-patient communication. Family members were believed to improve recovery after surgery by providing emotional and physical support for the patient. Family involvement was seen as providing the nurse a sense of security, which in turn improved care quality. If family members transferred their own stress to the patient and limited self-care activities, family involvement could be seen as hindering the patient's recovery. The patient is the nurse´s number one priority, and nursing may become more complicated if the family consumes the nurse's time, space, and energy. Some nurses believed that family involvement could become an intrusion on patient integrity and autonomy, an impairment of nurse-patient communication, and a safety hazard when participating in care in the intensive care unit.

Including the family in their mission
Nurses reported that they believed that including the family in their mission was of importance for the sake of the family. Family involvement was seen as improving the family's health, increasing the family's sense of coherence, giving the family a sense of security, and enhancing the family´s comprehension of the course of the disease. The nurses considered themselves to have an extended responsibility to care for not only the patient but also the family. Welcoming the family, appreciating the family, and supporting the family members' own choices regarding their level of involvement was said to be a part of the nurse's work.

Influential aspects
The most prominent components influencing nurses' attitudes were their professional experiences of meeting family members as a nurse and at times their personal experiences of being a family member. Several nurses reported using their own personal preferences regarding family involvement as a guide when caring for families. The patient's wishes and how the nurse understood the relationship and Table II. The mixed method merging and meta-inference of three datasets: An example from the side-by-side joint display analysis.   functioning within the family were also considered to affect nurses' attitudes towards family involvement in individual situations. The nurse-family relationship was seen as influencing collaboration between the nurse and the family. Organizational conditions, such as the context, policy of care, and attitudes of colleagues, were more general components described. Family members of a person cared for in the intensive care unit for an extended period of time were often described as having a higher priority than the family of a patient who had an elective surgery without complications.

Results from interviews with the medical doctors
Analysis of the twenty interviews with the MDs generated four generic categories: caring relationship, complicating care, striving for the patient's best and frames of reasoning. Quotes illustrating the categories are displayed in Table VI.

Caring relationship
In the category caring relationship, the MDs described trust as being of great importance for the family and the MD. The MDs aimed for the MD-family relationship to be supportive for the family. The relationship is built on trust, providing the family with honest and situational information. The MDs balanced information regarding patient outcomes, thereby trying to prepare the family for the worst while simultaneously giving them hope and avoiding unnecessary stress. Surgeons as well as anaesthesiologists emphasized the importance of the postoperative phone call undertaken by the surgeon to the family in establishing contact between the MD and the family. Family members were seen as collaborative partners who should be welcomed, supported, and cared for. The MDs described themselves as being attentive to the strain that involvement can place on the family and explained how they encouraged family members to preserve their resources by limiting the family's bedside presence. Supportive conversations and displays of empathy and understanding for family members were examples of acts of caring for the family.

Complicating care
The category complicating care entails descriptions of situations when MDs perceived family involvement as challenging and examples of how the MDs acted when family involvement complicated a situation. Cultural differences regarding expectations of health care services and communication were described as demanding. Large families were considered to take space and time and were sometimes burdensome for the MDs. Difficult conversations with families regarding adverse events or death were reported as a heavy responsibility for the MDs. Worry, guilt, and fear of being accused of mistreatment were prominent feelings in connection to difficult conversations with family members expressed by some MDs. A few MDs expressed rare instances when family members could be dangerous for the patient, for example, in domestic abusive relationships. The MDs considered themselves obligated to act when problems with family involvement occurred. Restriction of visitation and shifting focus back to the patient were other actions undertaken by the MDs when problems with family involvement occurred.

Striving for the patient's best
The MDs noted that the family usually was striving for the patient's best by safeguarding the patient's interests and giving the MD information regarding the patient's unique situation. Attitudes regarding family members acting as experts on the patient's needs and wishes were described on a continuum from negative to positive. The family was considered to know the person who was now a patient, thereby possessing knowledge that could improve the patient's care and recovery. Family members acting as experts on the patient's wishes were believed by some MDs to hinder the patient from speaking for themselves. Without family support, safeguarding of the patient's autonomy was considered to become the responsibility of the MDs and the care team. The MDs exemplified how family members could improve patient health and promote patient recovery by being physically, psychologically, and cognitively supportive. The family was viewed as giving the patient healing care and love and motivating the patient to come home.

Frames of reasoning
The MDs' frames of reasoning regarding their attitudes towards family involvement in care were set by their experiences, the health-care mandate, the family´s individual needs and the MD's ethical approach. They did not believe their attitudes had changed over time, but their professional experience had made encounters with family members easier. Some MDs described how personal experiences of being a patient or being a family member had made their attitudes regarding family involvement more positive. Professional experiences of being questioned or reported for clinical errors had in some instances led to more negative attitudes. Policy and praxis regarding health care professionals' responsibility for the family and the family's responsibility to be involved, as well as hospital environment and time limitations, were reported to influence MD attitudes. Some MDs stated that their attitudes towards family involvement varied between care settings. Patients experiencing complications or requiring intensive care were regarded as being in greater need of family involvement than patients undergoing elective heart surgery without complications. Some MDs thought that a person's attitudes towards family involvement could not be generalized. Descriptions of how families should be involved in an individualized manner were highlighted. The MDs' perceptions of the family´s experiences and relationships affected the MDs' beliefs about the individual family's practice of involvement. Family involvement was considered an ethical aspect of care and a duty for the MDs. A principle of treating others the same way you want to be treated yourself was commonly applied by the MDs in relation to family involvement in care.

Mixed-methods merged concepts
The integration involved merging the results from the quantitative and qualitative data so that a comparison could be made, and a more complete understanding emerged than provided by the qualitative or the quantitative results alone.
Preliminary themes were initially identified in the qualitative material as 1) positive attitudes, 2) negative attitudes, 3) family care, 4) components affecting attitudes. Thereafter, the descriptions of the FINC-NA subscales, the descriptive and analytical statistics and number of items corresponding to the themes was contrasted against all categories over the two qualitative datasets.
Attitudes from the three datasets were merged into four final concepts, illustrated in a visual side-byside joint display (Figure 2). Convergent concepts were supporting, informing and improving care and caring for the family. The concepts depending on the situation and impairing care were divergent. The main finding, a concept overarching all concepts, was the attitude that the importance of family involvement in open-heart surgical care depends on the situation.

Discussion
In this study, it was found that family involvement was foremost regarded as important for the patients´ health and recovery. These attitudes were merged into the convergent concept of supporting, informing and improving care. Nurses and MDs working in open-heart surgical care considered family involvement to be important for the family members as well as for the patient under certain conditions, as shown in the convergent concept of caring for the family. Components that the participants themselves reported as affecting their attitudes were presented. These self-reported components were not always supported by the statistical analyses of the quantitative material, and they are discussed in the divergent concept depending on the situation. The negative attitudes held by nurses and MDs were not as prominent as their positive attitudes. Nevertheless, these negative attitudes need to be addressed since these areas are of greatest importance for improvement. These aspects were merged into the divergent concept impairing care.

Convergent concepts: supporting, informing, and improving and caring for the family
The most prominent aspect of nurses' and MDs' attitudes towards family involvement in open-heart surgical care was illuminated in the convergent concept supporting, informing and improving care. This concept entails how family involvement was seen as supporting the patient, providing valuable information for the nurses and MDs and improving quality of care and postoperative recovery. Several of these aspects have previously been highlighted by patients and family members (Bélanger et al., 2018;Mackie et al., 2019) and surgeons (Jordan et al., 2014). The predominant positive attitude towards family involvement may also be reflected in the construct of the FINC-NA. In our mixed-methods merging, 18 out of 26 items seemed to "belong" to the concept supporting, informing, and improving reflecting positive attitudes. After the refinement of the FINC-NA, ceiling effects persisted (Saveman et al., 2011). These were suggested by the original author to be explained by the socially undesirable attitude of discarding the importance of family involvement in care (Saveman et al., 2011).
The overall positive rating of attitudes in our study was supported by the qualitative material. One could, however, question the MDs' emphasis on informing the family and question whether these practices truly are inclusive and an expression of mutual information sharing as perceived by patients and family members. MDs are often aware of how the timing and delivery of information can affect how the receiver retains the information given (Jordan et al., 2014). Family members express how shock, anger (Robley et al., 2010) and information that is unadjusted for the person´s level of health literacy (Mackie et al., 2019) may interfere with the message. Patients and family members have expressed a need for a dedicated professional who can bridge the gap in communication between the family and the care team, as well as between different members within the care team (Mackie et al., 2019).
Family, as a part of the health care mandate, was illuminated in the concept caring for the family. This concept was convergent over all datasets. It was considered to be important to care for family members in addition to the patient. Surgeons, in a previous study, highlighted how they consider communication to alleviate anxiety for family members (Jordan et al., 2014). The concept of caring for the family appeared to be prioritized more when the patient's hospital stay was prolonged due to the severity of illness or Table IV. Group differences in the Families' Importance in Nursing Care-Nurses' Attitudes (FINC-NA), scale and subscale results.  complications. This attitude emerged in the qualitative datasets and could explain why the ratings on the Fam-OR scale were lower than those on the other subscales, being predominantly neutral with a median score of three for three out of four items. The Fam-OR scale concerns the importance of support for the family. The interpretation of Fam-OR scores that was made after the mixed-methods merging-that the importance of supporting the family could depend on the severity of the patients' condition-might not have been made without the mixed-method

High score = positive attitudes on all items and scales
approach. An alternative interpretation could have been that support for families was not as important as the other aspects covered by the FINC-NA. Having a postgraduate diploma in nursing was associated with more positive attitudes in our sample. The majority of nurses holding postgraduate diplomas in this study were in intensive care. The association between positive attitudes and postgraduate diplomas could thus be an expression of the attitude that family involvement is more important in the intensive care setting than in the step-down or surgical ward setting. Data specifying whether the nurses worked in the surgical ward, step-down unit or intensive care unit were not collected; therefore, it was not possible to compare these groups. Previous research regarding how the postoperative care experience differs between patients and families of patients undergoing elective emergency surgery is inconclusive but indicates that a prolonged stay in the intensive care unit predisposes them to negative experiences (Göktas et al., 2016) and that family members have specific stress-related information needs in relation to intensive care (Joseph et al., 2015). On the other hand, the need for family involvement is expressed by patients and family members of patients undergoing elective open heart surgery regardless of complications and adverse events (Bjørnnes et al., 2019;Joseph et al., 2015;Kemp et al., 2020). The patient and family experience on this topic seems to need further investigation prior to directing resources in either course.

Divergent concepts: depending on the situation and impairing care
Components affecting the nurses' and MDs' attitudes towards family involvement were merged into the divergent concept of depending on the situation. The MDs and the nurses stated that their attitudes regarding family involvement depended on several factors, such as family functioning, organizational factors, and care setting. The ethical approach was an influential aspect reported by the MDs in this study that is important to investigate further when exploring health care professionals' attitudes towards family involvement in care since it is not asked about in the FINC-NA. The nurses in this study did not report about the ethical aspect of family involvement in their care in the qualitative data set to the same degree as the MDs. Divergence in this aspect might be due to differences between nurses and MDs views on why and how family involvement is important.
Regarding experiences being influential on the nurses' and MDs' attitudes, the concept was divergent. Both nurses and MDs described how having the experience of being a family member influenced their attitude towards family involvement, but there were no statistically significant differences regarding these aspects in the quantitative material. The divergence could be explained by methodology and differences between paradigms. It could be hypothesized that the nurses and MDs participating in this study whose attitudes were affected by their experiences elaborated on this in the qualitative material. In the quantitative material, the experiences of being a patient or family member was reported as either "yes" or "no", hence both significant and nonsignificant experiences for the persons' attitudes were reported. For example, the experience of being an adult child to a parent with a severe chronical condition may influence ones' attitude towards family involvement in care to a greater extent compared to being an adult child to a parent in need of hospital care on one occasion. In the quantitative dataset this was not adjusted for. Another interpretation of this divergent finding is that perhaps nurses' and MDs' subjective beliefs about how their personal experiences influence their attitudes cannot be generalized statistically on group level. Evidence regarding whether personal health care experiences affect the overall rating in the FINC-NA from previous studies is contradictory; some have not found this association (Blöndal et al., 2014;Østergaard et al., 2020), while others have (Linnarsson et al., 2015). During the development of the FINC-NA, it was learned that the answers could not be dichotomized because the answer depended on the situation , supporting the concept of depending on the situation in this study. The influence of organizational conditions was reported as divergent over the three datasets regarding having a lack of time for families. A few MDs and several nurses reported having a lack of time for families in the qualitative material. This finding was not reflected in the FINC-NA Fam-B subscale, where all items had a median of four, indicating a general attitude of having time for families in this population of nurses as one item specifically asks about this in the Fam-B subscale. Time restraints have previously been described by nurses as a factor influencing their involvement of families in care, stating that their number one priority is the patient (Mackie et al., 2018).
Negative attitudes over the three datasets were merged into the concept of impairing care. How family involvement may impair patient care and recovery was described in the two qualitative datasets, making it convergent between the nurses and MDs. The nurses and MDs also expressed that family involvement could complicate their work. This was not shown in the quantitative results in the Fam-B scale, making the concept divergent between paradigms. There are no questions on the FINC-NA asking about how family involvement can be harmful for the patient, which implies divergence between the quantitative and qualitative material. This is an attitude in need of further exploration in future research. In our study, the MDs described having some difficulties caring for families of various cultural backgrounds. This was interpreted as divergent from the nurses' experiences, possibly due to differences in data collection strategies. Perhaps, describing negative aspects and experiences would require time for reflection and report building, which is more commonly achieved during a qualitative interview compared to answering a survey. In a meta-synthesis of nurses' experiences of caring for culturally diverse families in hospitals (Murcia & Lopez, 2016), experiences similar to those expressed by the MDs in this study were found. Difficulties communicating, a lack of space for all family members and the violation of visitation policy are some examples of barriers described by nurses in relation to culturally diverse families (Murcia & Lopez, 2016).
In health care, it is important to provide competent transcultural care (Health Research & Educational Trust, 2013). Patient and family stressors related to open-heart surgery are contextual and have cultural dimensions (Sedaghat et al., 2019). Understanding and flexibility are key when caring for culturally diverse families (Murcia & Lopez, 2016). Transcultural competence involves an understanding and exploration of health-related beliefs in different cultures and contexts (Health Research & Educational Trust, 2013). The illumination of beliefs about illness and health is also a core concept in family-centred care that is applicable to a broad spectrum of care contexts (Shajani & Snell, 2019). Therefore, it could be that education on family-centred care practices, such as illuminating families' health and illness beliefs, could reduce negative attitudes and facilitate family involvement in care when caring for families from different cultural backgrounds in this context.
Patients and family members have, as previously stated, expressed a need for a dedicated professional who can bridge the gap in communication between the family and the care team. To enhance family involvement in care, this bridging professional would preferably have competency in family-centred care. With a family-centred care approach, the family is treated as a system in which all parts affect one and another (Bell, 2013;Shajani & Snell, 2019). Health and illness are considered a family affair, and the most effective care strategies are those targeting the whole system at once (Bell, 2013;Shajani & Snell, 2019). Competency in family-centred care would diminish the subjective practice of having family involvement depending on the situation from the professionals' perspective and instead having the family preferences as the main focus when planning and delivering open-heart surgical care. Familycentred care with the involvement of family cannot be accomplished if not approached interprofessionally (Naef et al., 2020). It is therefore important to have a team-based approach if family-centred care is introduced in the context of open-heart surgery.

Strengths and limitations
This study has strengths and limitations that need to be addressed. By using a joint display in the merging and meta-inference processes, validity of these inferences was strengthened (Creswell & Plano Clark, 2018). The interview guide used in this study contributed to consistency in qualitative data collection and therefore enhanced dependability. Furthermore, the interview guide was influenced by the FINC-NA, and the open-ended questions for the nurses were intended to ask questions similar to those for the MDs. Using parallel questions between different groups in a mixed-methods convergent parallel design facilitates the merging process and is a strategy to minimize validity threats in mixed-method convergent design studies (Creswell & Plano Clark, 2018). Having different populations in the two paradigms made the mixed-methods merging and inference in this study complicated, as previously described in the literature (Creswell & Plano Clark, 2018). On the other hand, the inclusion of different populations for the different data collection strategies facilitated the usage of appropriate quality criteria according to paradigm, important for minimizing validity threats in mixed-methods studies (Creswell & Plano Clark, 2018). The FINC-NA has previously been applied to MDs working in neonatal care, with the substitution of the term "nursing care" for "care" (Naef et al., 2020). Even though the present study shows many similarities in attitudes between nurses and MDs, there are reasons to believe that an instrument developed for nurses' attitudes towards family involvement in nursing care should not be directly applied to MDs attitudes towards family involvement in care as the instrument is not validated for the MD population. Another potential validity threat in convergent mixed-method studies is "failing to resolve disconfirming results" (Creswell & Plano Clark, 2018, p. 251). The authors of this study consider that suggestions for resolving the inferences of divergent concepts have been presented. However, wether these inferences can be considered valid is debatable.
The multidisciplinary composition of the research group may have contributed to the strengthening of credibility regarding qualitative analysis. Credibility was further enhanced by recruiting study participants from several different departments. Site credibility reduces the risk of having local factors influence the results (Shenton, 2004). Regarding transferability and generalizability, one problem was mutual between the paradigms, that is, selection bias. The aspiration to recruit all 650 patients who fulfilled the inclusion criteria in the cross-sectional study was part of the attempt to enhance the generalizability. The low response rate, however, limited this effect. The low response rate could be explained to some extent by the high strain on nurses during the COVID-19 pandemic in 2020. It is possible that the persons willing to participate in this study were the ones most favourable towards family involvement in the open-heart surgical care setting. This could, on the other hand, also be an advantage in the qualitative paradigm, where interested participants may have been able to provide richer data (Patton, 2015). The MDs participating in this study may also have considered the contribution to research to be important since 55% of them held a doctoral degree. Interviewing via a videoconferencing platform (i.e., Zoom) could have affected the richness of the data. The richness of the data could also have been affected by the fact that the first author had a professional relationship with some of the interviewees. These MDs could have responded in a more positive way, giving more positive selfdescriptions or responding in a way they believed that the first author would want them to, thereby leading to socially desirable responses (Malham & Saucier, 2016). However, the elaborative answers from the MDs and their willingness to share their experiences implied that this was not a problem in the present study. The restrictions of family visitations during the COVID-19 pandemic and the heavy workload during the data collection period could have influenced the results of this study. One strategy targeting this limitation was the instructions to both nurses and MDs to answer while having the normal situation in mind.

Conclusions
This study has provided knowledge regarding attitudes among nurses and MDs towards family involvement in open-heart surgical care. Foremost, positive attitudes, including views on how family involvement improves postoperative recovery, have been illuminated and could be regarded as a basis for familycentred care practices. Some areas of improvement in terms of negative attitudes could be targeted by implementing structured assessment of family functioning and illness beliefs. Competencies in familycentred practices and transcultural care could enhance family involvement in the open-heartcare context. There are organizational demands to further improve family involvement, such as prioritizing time, providing physical space for families and having family-centred policies. Family involvement in openheart surgical care may be necessary due to the patient's and family's unique needs in relation to open-heart surgery. Identifying those needs, as opposed to letting one's own unconscious personal beliefs determine the extent of family involvement, demands ethical reasoning and family care competency among all members of the team.

Notes on contributors
Anna Drakenberg, RN, MSc, is a doctoral student in the Department of Medical Sciences, School of Health Sciences at Örebro University, Sweden. Her research focuses on family-centered care in the context of open-heart surgery.
Mialinn Arvidsson-Lindvall, RPT, PhD, is affiliated with the School of Health Sciences in the Faculty of Medicine and Health, Örebro University, Sweden. Her research is related to elderly and physical activity, effect and experiences.
Elisabeth Ericsson, RNA, PhD, Associate Professor in anesthesia care, is a senior lecturer at Örebro university, Sweden. Her research focus is on pre-operative preparation and postoperative support for the families of patients undergoing anesthesia, surgery, and medical procedures with the aim of minimizing negative emotional reactions, achieving optimal pain and distress control in patients, and improving the quality of care.
Susanna Ågren RN, PhD, Senior associate professor in intensive care nursing at Linköping university, Sweden. Her research focus has been to meet the family individually, as a group, but also interactive. By evaluating this in randomized studies, focus groups and individual interviews in different research groups; burden, strain, relationship, health-related quality of life, hope, self-care, empowerment.
Ann-Sofie Sundqvist, RNA, PhD is affiliated with the School of Health Sciences in the Faculty of Medicine and Health, Örebro University, Sweden. Her research is related to family involvement after cardiac surgery, children's health and well-being, surgical site infections and bacteria contamination in the operating room, as well as daily life as perceived by people with funnel chest.

Author controbutions
Study conception and design was performed by AD, EE, SÅ and ASS. AD collected the data. All authors participated in data analysis. The first draft of the manuscript was written by AD, and all authors gave critical feedback and edited previous versions of the manuscript. All authors read and approved the final version of the manuscript.

Data availability statement
Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available.